Discussion Question

Amy Watters, EdD, RHIA, FAHIMA, Amy Bergstrom, EdD, and Ryan Sandefer, MA, CPHIT

Abstract: This paper examines the importance and increasing need for health care prac­ titioners to develop cultural competence in an effort to engage patients in their care to minimize the health disparities that are found in predominately ethnic minority popula­ tions. Although Meaningful Use requires data collection related to race and ethnicity, there is no evidence to support that the data is being used to engage patients in a culturally competent way. Lessons learned from the field of education regarding strategies used to develop cultural competence in the teaching profession can be applied in the health care field. This paper argues that cultural competence and patient engagement are clearly linked.

Key Words: Patient Engagement, Meaning Use, Cultural Competence

P atient Engagement a n d M eaningful U se: A ssessing the Impact of the

EHR Incentive P rogram on C ultural C ompetence in H ealthcare

Background

It is predicted that healthcare in the United States will account for over 20% of the GDP by 2020 (Cuckler et al., 2013). The leading cause of death and the cause of 75% of healthcare spending is due to chronic health conditions (Hoyert, 2012). While the cost of care continues to rise, there is little indication that outcomes are im prov­ ing. Despite great attention and effort placed on patient safety since the publication of the w atershed Institute of M edicine report To Err is Human in 1999 that indicated betw een 44,000 and 98,000 deaths were caused annually by m edical errors, the quality of healthcare delivered in the United States has actually gotten worse (Clancy, 2009). Further, minority populations, in particular, are burdened w ith higher rates of disease, disability, death and more often receive lower quality health care (A nderson et al., 2003). Two strategies have em erged as im p o rta n t to alleviating these challenges: patient engagem ent, and culturally com petent healthcare.

Engaging p atients in their health care is a proven m eth o d to im prove outcom es and care coordination, w hich is w hy the Medicare and M edicaid EHR Incentive Program s m ade patient engagem ent a focus of the m ean­ ingful use standards (CMS, 2012). Requiring patient- centered practices, such as giving patients access to their health inform ation and providing them w ith electronic

Amy Watters, EdD, RHIA, FAHIMA and Amy Berg­ strom EdD, are faculty members at The College of St. Scho- lastica, Department of Health Informatics and Information Management. Ryan Sandefer, MA, CPHIT, corresponding author, is Chair and Assistant Professor of the Department and may be reached at: 218-625-4931 or: [email protected].

tools to com m unicate w ith healthcare providers, are m eant to encourage patients to use health inform ation technology to better u nderstand and participate in their ow n healthcare (CMS, 2013) The Center for A dvancing Health (2010) defines engagem ent as "actions individuals m ust take to obtain the greatest benefit from the health care services available to them." A lthough this defini­ tion focuses on behaviors of the patient rather than the actions of healthcare providers, in order to effectively engage an increasingly diverse population of patients in a m eaningful way, the cultural competence of healthcare providers m ust be examined.

There is a clear link betw een culturally com petent healthcare and im proved patient outcomes. According to Betancourt, Green, Carrillo, and Park (2005) "poorer health outcom es m ay result w hen sociocultural differ­ ences betw een patients and providers are not reconciled in the clinical encounter." (p.500) The U nited States has seen an upsurge of im m igration over the past several decades. In 2013, approxim ately 37% of the U.S. p o p u ­ lation identified them selves as belonging to a racial or ethnic m inority p o pulation (Census, 2014). A lthough m inority populations extend beyond race or ethnicity to include sex, sexual identity, age, disability, socioeconomic status, and geographic location, this pap er will focus on healthcare outcom es and practices related to racial and ethnic m inority populations, w hich suffer disproportion­ ately from disparities in healthcare. H ealthy People 2020 defines a health disparity as "a particular type of health difference that is closely linked w ith social, economic, a n d /o r environm ental disadvantage" (HHS, n.d.). Pro­ viding culturally com petent services has been identified as one strategy to eliminate such disparities, and improve healthcare quality.

Journal of Cultural Diversity • Vol. 23, No. 3 Fall 2016

Cultural Competence "Culture" refers to integrated patterns of learned core

values, beliefs, norms, behaviors and customs that are shared and transmitted by a specific group of people (CE, n.d.). Providing culturally competent services means that organizations are able to respond effectively to the lan­ guage and psychosocial needs of patients (Anderson et al., 2003). The goal of cultural competence in healthcare is to create a system and a workforce that are capable of providing the highest-quality care to all patients regard­ less of race, ethnicity, culture, or language (Betancourt et al., 2005). Traditionally the healthcare community has focused on addressing language barriers and translation as the panacea for engaging patients of minority cultures (Engebretson, Mahoney, & Carlson, 2008); however, patient engagement must reach beyond linguistic strategies. The cultural demographics of a patient exceeds far beyond language. C ultural com petence requires m astery of knowledge and skills that increase an individual's ability to provide care to diverse populations (Health Research & Education Trust, 2013). Acknowledging cultural patterns, specifically of a sociocultural nature, is critical to under­ standing how cultural practices impact the development of ways of thinking, remembering, reasoning, and problem solving (Rogoff, 2003). Cultural processes are present in everyday human activities and development, which in turn relate to the technologies we use and our institutional and community values and traditions (Rogoff, 2003).

In recent years cultural competence has gained attention from healthcare policymakers, providers, insurers, and educators as a strategy to improve quality and eliminate cultural disparities in healthcare (Betancourt et al., 2005). This is evident not only by the provisions established through the recent EHR Incentive Program, b u t also through a number of provisions established by the Afford­ able Care Act that require the U.S. Department of Health and Human Services (HHS) to address health disparities through activities such as coordinating national health disparities action plans, improving access to quality care for minority and underserved populations, and increasing the cultural competency of the healthcare workforce (Hib­ bard, Greene, & Overton, 2013). Much of this work is done through the HHS Office of Minority Health (OMH) which was established in 1986 to improve the health of racial and ethnic minority populations in response to higher rates of illness and death from health conditions for minority populations such as African Americans, Hispanic Ameri­ cans, and American Indians in comparison to the rest of the U.S. population (OMH, n.d.). In accordance with the Affordable Care Act, HHS adopted new data standards for the collection of race, ethnicity, sex, primary language, and disability status with the goal of reducing disparities by better understanding the causes of health disparities through the standardization, collection, analysis, and re­ porting of data (Office of Minority Health, 2013).

While the healthcare industry has acknowledged that cultural competence is a critical component for addressing care outcomes across all demographic strata, there is still work to be done regarding integrating cultural competence, patient engagement, and healthcare decision-making. Cultural competence is critical to healthcare, as culture and health are strongly linked (Hayes-Bautista, 2003). There is evidence to support the need for increased cultural com­ petence in health care due to the changing demographics

of patients, high health care disparities among ethnic mi­ norities, and the fact that cultural competence improves patient engagement (Anderson et al., 2003). While we know there is a link between cultural competence and how patients are engaged in their healthcare, the current EHR Incentive Program does not have the explicit goal of engaging patients in a culturally competent manner. While data collection standards have been adopted and technical functions have been implemented as part of this program, there is a lack of focus on using the information and technology to explicitly curb health disparities.

The Role of the EHR Incentive Program One of the keys to ending health disparities and im­

proving health outcomes is engaging patients through culturally competent healthcare. The use of health infor­ mation technologies has been highlighted as one method for addressing these disparities. According to the National Partnership for Action to End Health Disparities (NPA),

Culturally and linguistically competent health care is based on a set ofbehaviors, attitudes, practices and poli­ cies that enable healthcare providers to better diagnose and treat patients of different cultural backgrounds. Recognition of cultural differences enhances rather than hinders understanding. Health care services that are respectful of and responsive to the health beliefs and practices of diverse patients, and that build trust, can help bring about positive health outcomes (Anderson et a l, 2003)

In addition to recognizing cultural differences, there is a relationship between patient access to health information (i.e. patient engagement) and care outcomes. The challenge is how best to provide patients access to health information in a culturally competent manner. The recently created EHR Incentive Program and its meaningful use requirements has created a platform for "engaging patients" (i.e., provid­ ing access to health information in electronic format) with health information and technology, as well as for collect­ ing additional information about patients' race, ethnicity, language, and communication preferences(CMS, 2012).

The Centers for Medicare and Medicaid Services (CMS) acknowledged the im portance of patient engagement and cultural competence when they included priorities, objectives, and measures related to both in the EHR Incen­ tive Program under the Health Information Technology for Economic and Clinical Health (HITECH) Act which emerged from the American Recovery and Reinvestment Act (ARRA) of 2009 . The EHR Incentive Program was developed to increase adoption of certified electronic health record systems among U.S. Eligible Professionals (EPs) and Eligible Hospitals (EHs), promote the use of these systems for secure health information exchange to improve care coordination, and improve care outcomes and healthcare transparency by using these systems for submitting electronic clinical quality measures The Incen­ tive Program provides incentive payments for EPs and EHs that meaningfully use certified Electronic Health Record (EHR) technology to meet the objectives required by the program (CMS, 2012)

Due to the growing literature related to the impact patient engagement has on health outcomes, the Incen­ tive Program includes "engage patients and families

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Table 1. Meaningful Use Objectives and Measures Related to Patient Engagement Through Access to Health Information

Stage 1 Objective Stage 1 M easure Stage 2 Objective Stage 2 Measure

Provide patients with an electronic copy of their health inform ation (including diagnostic test results, problem list, medication lists, medication allergies), upon request

More than 50% of all patients o f the EP who request an electronic copy of their health inform ation are provided it within 3 business days

Provide patients the ability to view online, download and transm it their health inform ation within fo u r business days o f the inform ation being available to the EP

i. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided tim ely (available to the patient within 4 business days after the inform ation is available to the EP) online access to their health information

ii. More than 5% o f all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transm it to a third party their health information

Provide clinical sum m aries for patients for each office visit

Clinical sum m aries provided to patients for more than 50% of all office visits within 3 business days

Provide clinical summ aries for patients for each office visit

Clinical sum m aries provided to patients within one business day fo r more than 50% o f office visits

Provide patients with tim ely electronic access to their health inform ation (including lab results, problem list, medication lists, medication allergies) within four business days o f the inform ation being available to the EP

More than 10% of all unique patients seen by the EP are provided tim ely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health inform ation subject to the EP’s discretion to withhold certain inform ation

in their healthcare" as a policy priority and identifies mul­ tiple objectives and measures related specifically to patient engagement, which are listed in Table 1 (CMS, 2012). It is important to note that the EHR Incentive Program is being implemented in progressive Stages-the measures

included in each Stage require a greater amount of effort from healthcare providers. For example, the Stage 1 Ob­ jective for providing patients an electronic copy of their health information only applies to those patients who request access. The Stage 2 Objective requires at least 50%

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Table 2. Meaningful Use Objectives and Measures Related to Patient Engagement Through Data Collection Utilization

Stage 1 Objective Stage 1 Measure Stage 2 Objective Stage 2 M easure

Record demographics • Preferred

language • G ender • Race • Ethnicity • Date o f birth

More than 50% o f all unique patients seen by the EP have dem ographics recorded as structured data

Record the following demographics

• Preferred language

• Gender • Race • Ethnicity • Date o f birth

More than 80% of all unique patients seen by the EP have dem ographics recorded as structured data

Generate lists of patients by specific conditions to use for quality im provement, reduction o f disparities, research or outreach

Generate at least one report listing patients of the EP with a specific condition

Generate lists of patients by specific conditions to use fo r quality improvement, reduction o f disparities, research, or outreach

G enerate at least one report listing patients of the EP with a specific condition

Send rem inders to patients per patient preference for preventive/ follow up care

More than 20% o f all unique patients 65 years or older or 5 years old or younger were sent an appropriate rem inder during the EHR reporting period

Use clinically relevant inform ation to identify patients who should receive rem inders for preventive/follow -up care

Use EHR to identify and provide rem inders for preventive/follow -up care fo r more than 10% o f patients with two or more office visits in the last 2 years

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

More than 10% o f all unique patients seen by the EP are provided patient-specific education resources

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

Patient-specific education resources identified by CEHRT are provided to patients fo r more than 10% of all unique patients with office visits seen by the EP during the EHR reporting period

NEW NEW Use secure electronic messaging to com m unicate with patients on relevant health information

A secure m essage w as sent using the electronic m essaging function of Certified EHR Technology by more than 5% of unique patients seen during the EHR reporting period

NEW NEW Record patient fam ily health history as structured data

More than 20% o f all unique patients seen by the EP during the EHR reporting period have a structured data entry fo r one or more first-degree relatives o r an indication that fam ily health history has been 9 reviewed

Journal of Cultural Diversity • Vol. 23, No. 3 Fall 2016

of all patients to have access to their health inform ation in electronic format.

The EHR Incentive Program also includes "im proving quality, safety, efficiency, and reducing health disparities" as a priority policy, identifying m ultiple objectives and associated m easures that require the collection of specific inform ation on patients, such as race, ethnicity, com m u­ nication m ethod preferences, and preferred language (see Table 2) (CMS, 2012). Such inform ation can enable health­ care providers to be m ore culturally responsive to patient needs and preferences, pointing to the criticality of cultural competence and CMS's acknow ledgem ent of its im pact on p a tie n t engagem ent. Similarly, the A ffordable Care Act of 2010 required the adoption of "new data standards for the collection of race, ethnicity, sex, prim ary language, and disability status for self-reported data collected from population-based health surveys" (Hibbard et al., 2013). This collection of data is critical to providing culturally com petent health care to patients w hose dem ographics m ay not reflect those of the provider.

While data is being collected to m eet the m eaningful use requirements, there is currently no evidence to support that it is being used to actually engage patients in a culturally com petent way.

The C h allen ge of P rovidin g C ulturally Com petent Healthcare

The EHR Incentive Program is attem pting to infuse the healthcare system w ith evidence-based practices related to patient engagement. However, w hat w e also know from the literature is that engagem ent (patient or otherwise) is not one size fits all. M ultiple factors drive the level of patient engagement, including age, literacy, health literacy, gender, and ethnicity (Bhandari, Shi, & Jung, 2014; Goel et al., 2011; Turvey et al., 2012). W hile the EHR Incentive Program has m otivated the healthcare industry to make significant strides in the realm of being responsive to patient needs and preferences, there are still considerable challenges to succeeding in this task, particularly related to culture and ethnicity. As the num ber of ethnic m inorities and m ulti­ cultural patients and families rapidly increases, cultural competency becomes an essential skill for all healthcare providers (Park, Chesla, Rehm, & Chun, 2011). In order to m eaningfully engage increasingly diverse populations in their healthcare, it is essential to utilize culturally compe­ tent strategies. For example, the EHR Incentive Program requires the adoption and use of patient portals. However, research has show n that people of color are significantly less likely to use p a tie n t p ortals th an th eir C aucasian counterparts (Sarkar et al., 2010). A culturally responsive strategy w ould be to utilize EHR data on com m unication preferences and cultural characteristics to engage specific populations and develop educational m aterials and pro­ gram s tailored to m ore effectively engage ethnic m inority populations. Im plem enting these types of strategies to ensure effective adoption and use of technical systems have the potential to im prove clinical outcomes. According to Goode et al. (2006), cultural and linguistic competence are w idely recognized as fundam ental aspects of quality in health care. M easures of cultural competence have been developed and adopted in healthcare, b u t " [d e v e lo p in g measures that assess cultural hum ility and / or assess actual practice are needed if educators in the health professions and health professionals are to m ove forw ard in efforts to understand, teach, practice, and evaluate cultural compe­

tence" (Kumas-Tan, Beagan, Loppie, MacLeod, & Frank, 2007).

There is considerable evidence regarding the im pact of patient engagem ent, specifically through patient-centered care. Patients and families w ho are engaged w ith their healthcare and utilize their personal health inform ation have seen im proved chronic disease m anagem ent, patient safety, patient satisfaction, educational outcomes and over­ all com m unication w ith clinicians and other healthcare stakeholders (Harris, H aneuse, M artin, & Ralston, 2009; Turley, Garrido, Lowenthal, & Yi Yvonne, 2012). According to an estim ate by the Com m onw ealth Fund, patient- and fam ily-centered care that incorporates shared decision­ m aking can reap potential healthcare savings of $9 billion over 10 years (Schoen, 2007).

In order to effectively engage patients in their health­ care, a concerted effort m ust be m ade to im plem ent cultur­ ally responsive strategies. This is especially im portant as the U.S. population continues to diversify. As the dem o­ graphics of patients change and health disparities am ong ethnic m inorities rem ain, cultural competence is the key to im proved patient engagem ent (A nderson et al., 2003).

What can Healthcare Learn from Educators? Healthcare can learn from the field of education, which

has long considered cultural competence to be a critical component of effective teaching practices. As in healthcare, the changing dem ographics of the nation have also led to demographic changes in the nation's classrooms (Tenforde, Nowacki, Jain, & Hickner, 2012). Educators, like health care professionals, have h ad to develop skills and strategies to m eet the needs of a changing dem ographic population, which, as the U.S. Census Bureau (year) reports, will con­ tinue to diversify as the ethnic m inority population grows to become the m ajority by 2025. Education levels for the U.S. population as a whole are rising, b u t the picture is different for different racial and etihnic groups. According to the U.S. Census Bureau's report, "Educational A ttain­ m ent in the U nited States: 2009", m inority p o p u latio n graduation rates continue to hover at or below 60% while white students graduate near 80% nationwide. The national attention on the achievem ent gap, w inch describes the disparities of educational achievem ent am ong students, is well know n (Ryan & Siebens, 2012).

Like the disparities in healthcare, the field of education continues to face academic achievement disparities among different groups of students. According to the Center for Public Education, the persistence of significant disparities in educational attainm ent by race, income level, and ethnic group presents a serious challenge (CPE, 2012). The dis­ parities in academic achievem ent betw een groups of stu­ dents, prim arily students of color and Caucasian students, is referred to as the achievem ent gap (EducationW eek, 2011). To address educational disparities educators w ork from a m ulticultural fram ew ork to inform their practice in a w ay that utilizes culturally com petent teaching strategies. According to the N ational Education Association (NEA (2014), cultural competence is key to enabling educators to be effective w ith students from cultures other th an their own. More often than not, teachers in today's classrooms do not m irror the diversity of the students in their classrooms. The NEA (2014) reports the num ber of m inority teachers nationw ide is not representative of the num ber of m inority students.

Journal of Cultural Diversity • Vol. 23, No. 3 Fall 2016

Multicultural education is not a new concept. Rooting itself in intercultural development in the 1920's, the move­ ment began as populations across the United States began to shift due to first and second- generation immigrants (Gollnick & Chinn, 2013). The idea behind multicultural education is to create a more equitable and just educa­ tional experience for all students (Banks, 2002). Gollnick and Chinn (2013) describe multicultural education as an education that acknowledges the importance of diversity to promote equity and social justice in the teaching and learning process. Banks (2002) describes multicultural edu­ cation as a reform movement that aims to make significant changes in a student's educational experience.

To address educational disparities in the field of edu­ cation, several theoretical frameworks are used to inform multicultural education and cultural competence of teach­ ers. The NEA (2014) considers cultural competence to be a key policy issue, and has outlined four cultural compe­ tence skill areas to better equip educators to be culturally competent practitioners who can serve a diverse group of students:

1) Valuing diversity: Accepting and respecting dif­ ferent cultural backgrounds, customs, traditions, values, and m odes of communicating.

2) Being culturally self-aware: U n derstanding that ractitioners' ow n cultures and experiences shape ow they interact w ith others.

3) U nderstanding the dynam ics of cultural interac­ tions: Knowing that m any factors im pact interac­ tions across cultures.

4) Institutionalizing cultural know ledge and ad ap t­ ing to diversity: Designing services based on an und erstan d in g of others' cultures to better serve diverse populations.

The NEA (2008) asserts that these competencies need to be addressed through pre-service education, ongoing

rofessional development, and licensure. Because many ealthcare professionals are required to maintain licensure

or certification through continuing education, boards could require professional development in these areas. Moreover, because healthcare practitioners largely graduate from pro­ grams that must meet specific accreditation requirements, this content could be adopted within academic programs early in a healthcare professional's career training. As Romanello and Holtgrefe (2009) point out, it has become necessary that healthcare education include multicultural curriculum content.

The parallels between the achievement gap in education and the disparities in healthcare that exist with diverse populations are similar. Disparities in educational achieve­ ment is in part being addressed by developing and sustain­ ing culturally competent teaching and learning strategies just as should be developed in the field of healthcare. In order to change negative outcomes, we need to change how we deliver instruction (MMEP, 2012); the same can be said for healthcare delivery. For example, Seeleman, Suurmond, and Stronks (2009) propose a conceptual cul­ tural competence framework to emphasize the importance of taking care of ethnically diverse patient populations. This framework may be a first step in guiding healthcare professionals in delivering culturally competent care.

C onclusion The EHR Incentive Program has catapulted the health­

care industry forward in terms of electronic health record adoption, healthcare data collection and data standard­ ization, data quality, and health information exchange. While the Program has resulted in major advancements in eHealth technology adoption and data utilization, the dis­ connect between requiring increased levels of demographic data on each patient but not using it for patient engage­ ment purposes is an area that needs attention from both the Centers for Medicaid and Medicare Services and the Office of the National Coordinator for Health Information Technology. Because the EHR Incentive Program includes multiple Stages, there is an opportunity for these federal agencies to include objectives specifically related to cul­ turally competent healthcare. At present, we do not know if the electronic health record technology that has been adopted since the implementation of the EHR Incentive Program is having an impact on different patient popu­ lations (e.g. race and ethnicity) across multiple outcome measures, such as patient satisfaction or clinical-related outcomes.

Culturally competent education is integrally linked to acknow ledging, respecting, and incorporating the student's backgrounds and cultural framework into the teaching and learning process. This approach has worked to address disparities in academic achievement. Patient engagement is one of healthcare's methods for addressing health disparities by putting information and knowledge into the hands of patients. The transfer of knowledge from the provider to the patient can only happen if there are multicultural strategies in place to increase the efficacy of patient learning. As the EHR Incentive Program continues to advance the methods in which patients are engaging in their healthcare through technology, it is critical that the Program approach its objectives and measures through a culturally competent lens.

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Journal of C ultural Diversity • Vol. 23, No. 3 Fall 2016

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